Research Article: Clinical outcomes and risk-factor analysis of the Ponseti Method in a low-resource setting: Clubfoot care in Haiti

Date Published: March 14, 2019

Publisher: Public Library of Science

Author(s): Rameez A. Qudsi, Faith Selzer, Stephen C. Hill, Ariel Lerner, Jean Wildric Hippolyte, Eldine Jacques, Francel Alexis, Collin J. May, Robert B. Cady, Elena Losina, Pedro Gonzalez-Alegre.


The Ponseti Method has dramatically altered the management of clubfoot, with particular implications for limited-resource settings. We sought to describe outcomes of care and risk factors for sub-optimal results using the Ponseti Method in Haiti.

We conducted a records review of patients presenting from 2011–2015 to a CURE Clubfoot clinic in Port-au-Prince, Haiti. We report patient characteristics (demographics and clinical), treatment patterns (cast number/duration and tenotomy rates), and outcomes (relapse and complications). We compared treatment with benchmarks in high-income nations and used generalized linear models to identify risk factors for delayed presentation, increased number of casts, and relapse.

Amongst 168 children, age at presentation ranged from 0 days (birth) to 4.4 years, 62% were male, 35% were born at home, 63% had bilateral disease, and 46% had idiopathic clubfeet. Prior treatment (RR 6.33, 95% CI 3.18–12.62) was associated with a higher risk of delayed presentation. Risk factors for requiring ≥ 10 casts included having a non-idiopathic diagnosis (RR 2.28, 95% CI 1.08–4.83) and higher Pirani score (RR 2.78 per 0.5 increase, 95% CI 1.17–6.64). Female sex (RR 1.54, 95% CI 1.01–2.34) and higher Pirani score (RR 1.09 per 0.5 increase, 95% CI 1.00–1.17) were risk factors for relapse. Compared to North American benchmarks, children presented later (median 4.1 wks [IQR 1.6–18.1] vs. 1 wk), with longer casting (12.5 wks [SD 9.8] vs. 7.1 wks), and higher relapse (43% vs. 22%).

Higher Pirani score, prior treatment, non-idiopathic diagnosis, and female sex were associated with a higher risk of sub-optimal outcomes in this low-resource setting. Compared to high-income nations, serial casting began later, with longer duration and higher relapse. Identifying patients at risk for poor outcomes in a low-resource setting can guide counseling, program development, and resource allocation.

Partial Text

Congenital clubfoot is one of the most common musculoskeletal deformities at birth, affecting 1–2 babies per 1000 live births.[1–3] This accounts for approximately 150,000 to 200,000 newly affected children annually worldwide, 80% of whom are believed to be born in low and middle-income countries (LMIC).[3–5] A recent meta-analysis of clubfoot in LMIC finds an incidence in African regions of 1.11 per 1000 and in the Americas of 1.74 per 1000, projecting 43 new babies born with clubfoot each year per million population in Africa and 30 per million in the Americas. [6] Without treatment, such children may suffer life-long deformity, disability, and profound social stigma in many cultures impeding access to education and productivity.[5, 7, 8]

In this report, we analyze four years of experience with the Ponseti method in a low-resource setting, as applied to clubfoot care in Port-au-Prince, Haiti. We provide benchmark metrics and demonstrate gaps in care including delayed presentation, longer duration of casting, and increased relapse rate compared to surveyed standards in high-income countries. Furthermore, in this study sample we identify prior treatment as a risk factor for delayed presentation; non-idiopathic diagnosis, missing/unknown place of birth, and higher Pirani score as risk factors for needing ≥ 10 castings; and female sex and higher Pirani score as risk factors for relapse.




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